Early Diagnosis of Periprosthetic Joint Infection of the Hip-Current Status, Advances, and Perspectives

Gomes, Luiz Sérgio Marcelino

doi:10.1055/s-0039-1693138

Luiz Sérgio Marcelino Gomes

School of Medicine of Uberaba, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil

Center of Studies of the Service of Surgery and Orthopedic- Traumatological Rehabilitation of Batatais, Batatais , SP, Brazil

http://orcid.org/0000-0003-1813-7171

Address for correspondence
Luiz Sérgio Marcelino Gomes, MD, PhD, Rua 7 de Setembro 466, Centro, Batatais, SP, 14300-000, Brazil (e-mail: marcelin@com4.com.br).

Conflicts of Interest

The author has no conflicts of interest to declare.

Figures (2)
Tables (3)

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Fig. 1
Asymptomatic patient submitted to total hip arthroplasty 4 years ago. Radiographically we observe the excessive wear of the polyethylene, not compatible with the period of service of the implants. (Fig 1. A–C). We performed revision surgery despite the absence of clinical manifestations or tests indicative of infection. Preoperative tests: ESR = 19mm, CRP = 29.2 mg/L, dimer D = 530 ng/mL Intraoperative aspiration of the hip revealed an abundant amount of purulent-looking liquid. (Fig. 1-D) We could not observe any signs of infected periprosthetic tissues, acetabular loosening or third body abrasion. (Fig. 1-E) Large area of osteolysis was observed in the posteromedial region of the proximal femur, which extended to the trochanteric region. After curetting the whitish and friable tissue, an extensive area of bone loss could be seen in the proximal femur. (Fig. 1-F) Intraoperative tests: Leukocyte esterase: +; Synovial leukocytes: 52,800; % Neutrophils: 50%. All cultures of periprosthetic tissue and 1 culture of synovial fluid (in blood culture medium) were negative after 8 days of incubation. Up to 18 months postoperatively, the patient was asymptomatic and without any changes in the serum markers for infection.

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Fig. 2
Modified American Academy of Orthopedic Surgeons algorithm (CIAP, 2013). Abbreviations: BAAR, Acid-alcohol-resistant bacilli, CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; XR, X-ray; SF, synovial fluid.

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Table 1
Periprosthetic Joint Infection (PJI) Diagnostic Criteria

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Table 2
Classification according to Tsukayama et al (2003)¹¹11 Tsukayama DT, Goldberg VM, Kyle R. Diagnosis and management of infection after total knee arthroplasty. J Bone Joint Surg Am 2003;85-A(Suppl 1):S75-S80

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Table 3
Analysis of combined incidence and clinical findings for nonspecific and specific periprosthetic joint infections regarding presentation time and type¹³13 Gomes LSM, Zullo SS, Pereira GA. Response to question Q118 (Hip and Knee): What clinical findings (e.g. fever, erythema, reduced ROM) are most sensitive and specific for the diagnosis of PJI? In: Parvizi, J and Gherke Thorsten. Proceedings of the Second International Consensus Meeting on Musculoskeletal Infections. Brooklandville, Maryland: Data Trace; 2018. p. 343-344

Diagnostic Criteria	Berbari et al (1998)⁴4 Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Ilstrup DM, Harmsen WS, et al. Risk factors for prosthetic joint infection: casecontrol study. Clin Infect Dis 1998;27(05):1247-1254		Musculoskeletal Infection Society (MSIS)⁵5 Parvizi J, Zmistowski B, Berbari EF, Bauer TW, Springer BD, Della Valle CJ, et al. New definition for periprosthetic joint infection: fromtheWorkgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011;469(11):2992-2994		Infectious Diseases Society of America (IDSA)⁶6 Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM, et al. Infectious Diseases Society of America. Executive summary: diagnosis andmanagement of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013;56(01):1-10		International Consensus on Periprosthetic Joint Infection (I ICM)⁷7 Parvizi J, Gehrke T, Chen AF. Proceedings of the international consensus on periprosthetic joint infection. Bone Joint J 2013;95-B (11):1450-1452
Diagnostic Criteria	Major criteria	Minor criteria	Major criteria	Minor criteria	Major criteria	Minor criteria	Major criteria	Minor criteria
Joint sinus tract	X		X		X		X
≥ 2 positive cultures from SF and/or PPT (identical MO)	X		X		X		X
Periprosthetic pus accumulation	X			X	X
Increased ESR and CRP in blood				X				X
Leukocytosis in SF				X				X
Neutrophilia in SF				X				X
Histology: PPT inflammation	X			X		X		X
Single positive culture (SF or PPT)				X		X		X

Infection type/features	I. Positive intraoperative culture	II. Early postoperative infection	III. Acute hematogenic infection	IV. Late chronic infection
Symptoms start after baseline surgery	____	Up to 4 weeks	After an asymptomatic period	After 4 weeks
Mechanism	____	Exogenous	Hematogenic	Exogenous or hematogenic
Most common etiological agent	Coagulase-negative Staphylococci (epidermidis)	Staphylococci (Coagulase-positive and negative), Gram-negative Bacilli	Coagulase-positive Staphylococci +, Streptococci	Staphylococci (Coagulase-positive and negative), Gram-negative Bacilli
Clinical presentation	Painful arthroplasty	Fever, inflammatory signs, persistent drainage, no sinus tract	Fever, inflammatory signs, no sinus tract	Fever, sinus tract, drainage, pus accumulation, local edema

(Combined) Clinical Findings	Analysis of the clinical findings for nonspecific PJIs				Incidence of the clinical findings for nonspecific and Specific PJIs.Average % (95%CI)
(Combined) Clinical Findings	N^oAC/Controls(N^o PJIs THR/ TKR/ others)	Sensitivity % (95%CI)	Specificity % (95%CI)	Accuracy % (95%CI)	Nonspecific PJI	Early postoperative PJI	Acute hematogenic PJI	Late chronic PJI
Pain	225/237 (77/18/ 0)	57.9 (47.3–67.9)	28.3 (22.6–34.5)	36.7 (31.5–42.2)	77.2 (74.5–79.9)	54.7 (51.3–58.0)	92.8 (89.1–96.6)	82.9 (77.5–88.3)
Fever	17/205 (62/3/ 0)	13.8 (6.5–24.7)	96.1 (92.5–98.3)	76.3 (70.7–81.2)	31.2 (28.2–34.1)	32.5 (29.4–35.5)	75.5 (71.3–79.7)	14.0 (10.4–17.6)
Periarticular inflammation ^a Combined for joint effusion/edema, heat and/or erythema.	113/716 (316/220/0)	14.9 (11.9–18.4)	94.7 (92.8–96.2)	61.8 (59.0–64.6)	35.9 (33.2–38.6)	49.0 (44.8–53.3)	69.7 (60.1–79.2)	18.4 (14.9–22.0)
Superficial disturbances at the surgical site ^b Composite for delayed healing, persistent non-purulent drainage and/or superficial dehiscence.	487/1,771 (538/392/ 0)	23.6 (21.3–26.1)	88.6 (87,0–90.0)	61.8 (59.9–63.5)	40.4 (37.5–43.2)	46.8 (40.6–53.0)	NR	24.1 (17.9–30.2)
Deep soft parts involvement ^c Composite for deep sinus tract, purulent drainage, abscess and/or extensive necrosis.	24/62 (4/17/ 3)	43.7 (29.5–58.8)	100.0 (97.0–100.0)	84.3 (78.0–89.4)	38.8 (35.4–42.1)	44.0 (40.7–47.4)	11.0 (8.1–14.0)	26.3 (21.8–30.9)
Joint dysfunction ^d Composite for rigidity and/or reduced range of joint motion.	NR	NR	NR	NR	74.4 (69.9–78.9)	NR	20.5 (1 reference)	41.7 (1 reference)
Total number of included PJIs(THR/ TKR/ others)	976 (561/412/ 3)	__	__	__	2523 (1421/ 1071/ 31)	902 (491/ 408/ 3)	435 (152/ 274/ 9)	607 (385/ 181/ 41)

[1] Address for correspondence
Luiz Sérgio Marcelino Gomes, MD, PhD, Rua 7 de Setembro 466, Centro, Batatais, SP, 14300-000, Brazil (e-mail: marcelin@com4.com.br).

Brasil

Brasil

Early Diagnosis of Periprosthetic Joint Infection of the Hip-Current Status, Advances, and Perspectives^* * Work performed at the Pró-Reitoria de Pós-Graduação of the Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil.

Abstract

Brasil

Brasil

Early Diagnosis of Periprosthetic Joint Infection of the Hip-Current Status, Advances, and Perspectives* * Work performed at the Pró-Reitoria de Pós-Graduação of the Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil.

Abstract

Early Diagnosis of Periprosthetic Joint Infection of the Hip-Current Status, Advances, and Perspectives^* * Work performed at the Pró-Reitoria de Pós-Graduação of the Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil.